Healthcare Provider Details

I. General information

NPI: 1619967106
Provider Name (Legal Business Name): DOUGLAS STEWART FITZWATER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 E 3RD ST
PORTAGEVILLE MO
63873-1402
US

IV. Provider business mailing address

1008 N MAIN ST
SIKESTON MO
63801-5044
US

V. Phone/Fax

Practice location:
  • Phone: 573-379-5467
  • Fax: 573-379-5671
Mailing address:
  • Phone: 573-472-7406
  • Fax: 573-472-7475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberR8N02
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberR8N02
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR8N02
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: